Understanding and preventing wrong-patient electronic orders: a randomized controlled trial
Journal of the American Medical Informatics AssociationPublished 30 June 2012Open access
Jason S. Adelman, Gary Kalkut, Clyde B. Schechter, Jeffrey M. Weiss, Matthew Berger, Stan Reissman
Citations121
SJR quartileQ1
SJR score2.04
SNIP1.95
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
Evaluating systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study found that electronic interventions can reduce the risk of these errors occurring.
Abstract
Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.
Keywords
MedicineHealth Professions
JAMARole of Computerized Physician Order Entry Systems in Facilitating Medication Errors
2,116 Citations2005Ross Koppel
JAMAEffect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors
2,091 Citations1998David W. Bates
Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.
Journal of the American Medical Informatics AssociationSome Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors
1,800 Citations2003Joan S. Ash
With a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.
PubMedEffects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.
1,338 Citations2003Rainu Kaushal, Kaveh G Shojania +1 more
Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems.
Journal of the American Medical Informatics AssociationThe Impact of Computerized Physician Order Entry on Medication Error Prevention
1,273 Citations1999D. W. Bates, Jonathan M. Teich +6 more
Computerized POE substantially decreased the rate of non-missed-dose medication errors, and a major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.
Health Affairs‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured
1,027 Citations2011David C. Classen, Roger K. Resar +8 more
It is found that the adverse event detection methods commonly used to track patient safety in the United States today-voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators-fared very poorly compared to other methods and missed 90 percent of the adverse events.
NatureUnited States Pharmacopeia
903 Citations1955J. H. Gaddum
The Pharmacopeia of the United States of AmericaFifteenth Revision, Fifth Revision is published.
Journal of the American Medical Informatics AssociationTypes of Unintended Consequences Related to Computerized Provider Order Entry
824 Citations2006Emily M. Campbell, Dean F. Sittig +3 more
Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future C POE projects.
Journal of the American Medical Informatics AssociationUnintended Consequences of Information Technologies in Health Care--An Interactive Sociotechnical Analysis
690 Citations2007M. I. Harrison, Ross Koppel +1 more
The model draws on prior studies of unintended consequences, along with research in sociotechnical systems, ergonomics, social informatics, technology-in-practice, and social construction of technology to capture common types of interaction.
Statistics in MedicineInterim analysis: The alpha spending function approach
569 Citations1994David L. DeMets, K. K. Gordon Lan
The alpha spending function approach is reviewed, and its applicability to a variety of commonly used statistical procedures, including survival and longitudinal methods are detailed.
New England Journal of MedicineEffect of Bar-Code Technology on the Safety of Medication Administration
558 Citations2010Eric G. Poon, Carol Keohane +13 more
Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors.
Journal of the American Medical Informatics AssociationThe Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry
501 Citations2007Joan S. Ash, Dean F. Sittig +4 more
It was found that hospitals experienced all eight types of unintended adverse consequences, although respondents identified several they considered more important than others, including those related to new work/more work, workflow, system demands, communication, emotions, and dependence on the technology.
JAMAHealth IT and Patient Safety: Building Safer Systems for Better Care
496 Citations2012David W. Chou
This report assesses how HIS can be designed, developed, implemented, monitored, and maintained to maximize safety and identifies seven publications presenting results of assessments of e-iatrogenic risk.
Journal of the American Medical Informatics AssociationDetecting Adverse Events Using Information Technology
472 Citations2003David W. Bates, R. Scott Evans +4 more
Computerized detection of adverse events will soon be practical on a widespread basis, and appears likely that these techniques will be adaptable in ways that allow detection of a broad array of adverse Events, especially as more medical information becomes computerized.
Journal of Biomedical InformaticsDetecting adverse events for patient safety research: a review of current methodologies
357 Citations2003Harvey J. Murff, Vimla L. Patel +2 more
This paper reviews the current methodologies for detection of adverse events and discusses their relative advantages and limitations, and presents a cognitive framework for error monitoring and detection.
Journal of the American Medical Informatics AssociationDoes Computerized Provider Order Entry Reduce Prescribing Errors for Hospital Inpatients? A Systematic Review
264 Citations2009Margaret Reckmann, Johanna Westbrook +3 more
The evidence-base reporting the effectiveness of CPOE to reduce prescribing errors is not compelling and is limited by modest study sample sizes and designs.
Journal of Biomedical InformaticsA framework for analyzing the cognitive complexity of computer-assisted clinical ordering
141 Citations2003J Horský, David R. Kaufman +2 more
A multifaceted cognitive methodology for the characterization of cognitive demands of a medical information system is presented, revealing that the configuration of resources in this ordering application placed unnecessarily heavy cognitive demands on the user, especially on those who lacked a robust conceptual model of the system.
Journal of Biomedical InformaticsTo err is not entirely human: Complex technology and user cognition
137 Citations2005J Horský, Jiajie Zhang +1 more
The JAMA study makes the characterization of technology-related medical errors its central thesis and points out that attention needs to be given to the errors CPOEsystems can cause in addition to theerrors they help toprevent and that many identified problems with C POEimplementations could in fact be easily corrected.
PubMedCPOE system design aspects and their qualitative effect on usability.
59 Citations2008Reza Khajouei, Monique W. M. Jaspers
It is shown that the manner in which a CPOE system is configured can have a high impact on ease of system use, task behavior of clinicians in ordering drugs, and medication errors.
Journal of the American Medical Informatics AssociationIdentifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System
54 Citations2008Ross Koppel, Charles E. Leonard +4 more
This measure offers a rapid, constant, inexpensive, and objective method to identify medication orders with a high probability of error and may also serve as a screening and teaching mechanism for physicians-in-training.
PubMedIncreasing the success of physician order entry through human factors engineering.
46 Citations2002Wendy Chan
Techniques from the field of human factors engineering (HFE) be used to enhance the interaction between technology and the physicians to increase the chance of a successful POE implementation.
PubMedThe cognitive complexity of a provider order entry interface.
36 Citations2003J Horský, David R. Kaufman +1 more
A cognitive analysis of clinician interaction with a commercial POE system revealed that the configuration of resources placed unnecessarily heavy cognitive demands on the user, especially those who lacked a robust conceptual model of the system.
Academic Emergency MedicineProviders Do Not Verify Patient Identity during Computer Order Entry
35 Citations2008Philip L. Henneman, Donald L. Fisher +6 more
The frequency of verifying patient ID during computerized provider order entry (CPOE) with two identifiers, including name, date of birth, or medical record number, was determined.
Journal of the American Medical Informatics AssociationMinimizing electronic health record patient-note mismatches
28 Citations2011Adam Wilcox, Yueh-Hsia Chen +1 more
The patient-note mismatch rate is low compared to published rates of other documentation errors, it can be further reduced by the design of the user interface, and the reduction in rates after the intervention was statistically significant.
Annals of PharmacotherapyIdentification of Patient-Controlled Analgesia Overdoses in Hospitalized Patients: A Computerized Method of Monitoring Adverse Events
27 Citations1994Julianne K. Whipple, Edward J. Quebbeman +4 more
A computer-based quality assurance method that detects narcotic overdoses associated with patient-controlled analgesia (PCA) use identified almost twice as many adverse incidents than were reported by the traditional hospital methods.
PubMedOops, Sorry, Wrong Patient!: A Patient Verification Process is Needed Everywhere, Not Just at the Bedside.
20 Citations2014Matthew Grissinger
Verification of patient identity is needed at all stages of clinical trials to establish patient identity and establish trust in the clinical practice.